INFECTION PREVENTION AND CONTROL

Starting with the Basics

Objectives

Speak to the relationship between Infection Prevention methods and reduced transmission of multidrug resistant organisms and C. difficile.

Explain the importance of hand hygiene including barriers preventing proper hand hygiene

Describe environmental cleaning issues and assessment methods for cleaning validation

Discuss recommendations for equipment cleaning and disinfection

List the personal protective equipment used to prevent the spread of organisms

MDRO Definition

Multi Drug Resistant Organisms

Microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents

Some common ones include: MRSA, VRE, CRE ESBL, and Acinetobacter

Colonized or Infected:What is the Difference?

• People who carry bacteria without evidence of infection (fever, purulent drainage, increased white blood cell count) are colonized

• If an infection develops, it is usually from bacteria that colonize patients

• Bacteria that colonize patients can be transmitted from one patient to another by the hands of healthcare workers

~ Bacteria can be transmitted even if the patient is not infected ~

Resistant Staphylococcus

MRSA-Methicillin-resistant Staphylococcus aureus causes a range of illnesses, from skin and wound infections to pneumonia and bloodstream infections that can cause sepsis and death.

Staph bacteria, including MRSA, are one of the most common causes of healthcare-associated infections.

Vancomycin is a common antibiotic used for treatment of MRSA infections. Staphylococcus aureus can become resistant to Vancomycin .

http://www.cdc.gov/mrsa/

Resistant Enterococcus

VRE -Vancomycin resistant enterococcus can live in the human intestines and female genital tract without causing disease.

VRE can cause infections of the urinary tract, the bloodstream, or of wounds associated with catheters or surgical procedures.

People with colonized VRE  do not need treatment.

Most VRE infections can be treated with antibiotics other than Vancomycin.

http://www.cdc.gov/HAI/organisms/vre/vre.html

Carbapenem Resistant Organisms

CRE - Carbapenem-resistant Enterobacteriaceae bacteria are difficult to treat because they have high levels of resistance to antibiotics. Klebsiella species and Escherichia coli (E. coli) are examples of

Enterobacteriaceae, a normal part of the human gut bacteria, that can become carbapenem-resistant.

Types of CRE are sometimes known as KPC (Klebsiella pneumoniae carbapenemase) and NDM (New Delhi Metallo-beta-lactamase). KPC and NDM are enzymes that break down carbapenems and make them ineffective. Both of these enzymes, as well as the enzyme VIM (Verona

Integron-Mediated Metallo-β-lactamase) have also been reported in Pseudomonas.

http://www.cdc.gov/HAI/organisms/cre/

ESBL Resistance

ESBL – Some bacteria product Extended Spectrum Beta Lactamase enzymes that mediate resistance to extended-spectrum third generation cephalosporins , but do not affect cephamycins (e.g., cefoxitin and cefotetan) or carbapenems (e.g., meropenem or imipenem).

K. pneumoniae, K. oxytoca, E. coli, and some Enterobacteriaceae, such as Salmonella species and Proteus mirabilis, and isolates of Pseudomonas aeruginosa can produce ESBLs.

http://www.cdc.gov/HAI/settings/lab/lab_esbl.html

Resistant Acinetobacter

Acinetobacter are gram-negative bacteria that cause of pneumonia, bloodstream infections, or wound infections among critically ill patients.

Many of these bacteria have become very resistant to antibiotics. May “colonize” a patient especially in tracheostomy

sites or open wounds. Can be spread to susceptible persons by person-to-

person contact or contact with contaminated surfaces.

http://www.cdc.gov/HAI/organisms/acinetobacter.html

Where Does C. difficile fit into this discussion?

Clostridium difficile is not a multidrug resistant organism

C. difficile is an anaerobic, gram-positive, spore-forming bacillus, first detected in 1935 in lower intestinal microbiota of healthy newborns.

C. difficile was thought to be nonpathogenic for nearly four decades

In 1978, C.difficile was identified as the primary cause of pseudomembranous colitis in patients treated with antibiotics.

http://www.apic.org/Resource_/EliminationGuideForm/59397fc6-3f90-43d1-9325-e8be75d86888/File/2013CDiffFinal.pdf

C. Difficile Facts

C. difficile infection (CDI) is the leading cause of antibiotic-associated diarrhea and a highly problematic healthcare-associated infection

The major risk factors for CDI are exposure to antibiotics, hospitalization, and advanced age.

The incubation period following acquisition is suggested to be short (median of 2–3 days).

There are two states of C. difficile: The vegetative stage does not survive long, but the spore state can persist in the environment for many months.

Transmission of MDRO

Transmission and persistence of the resistant strain is determined by:

Availability of vulnerable patients Selective pressure exerted by antimicrobial use Colonization pressure Utilization of prevention efforts

MDRO are often used as surveillance markers to monitor for IC breaches

CDC/HICPAC System for Categorizing Recommendations

Category IA Strongly recommended for implementation and strongly supported by well designed experimental, clinical, or epidemiologic studies.

Category IB Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale.

Category IC Required for implementation, as mandated by federal and/or state regulation or standard.

Category II Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.

No recommendation Unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exists.

CDC Recommendations

Two Tiered approach for prevention and control of MDRO in a healthcare setting

Tier one are general recommendations for routine prevention and control

Tier two are intensified MDRO control efforts to institute when MDRO rates are not decreasing, an outbreak or new MDRO organism is identified

http://www.cdc.gov/hicpac/pdf/MDRO/MDROGuideline2006.pdf

Guideline Area Emphasis

Administrative Measures/Adherence Monitoring MDRO Education Judicious Antimicrobial Use Surveillance Infection Control Precautions Environmental Measures Decolonization

Administrative Support

Provide administrative support and commit both fiscal and human resources to prevent and control MDRO transmission (IB)

Enforce adherence to Standard and Contact Precautions (IB)

Feedback to administration and staff on rates (IB) Participation in MDRO coalitions (IB) Effective communication (II)

MDRO Education

Staff education should occur as part of orientation and periodically based on facility assessment (IB)

Adherence to hand hygiene practices in conjunction with other control measures have been associated temporally with decreases in MDRO transmission in various healthcare settings.

Judicious Antimicrobial Use

Hospitals and LTCFs should have a multi-disciplinary process to review susceptibility patterns and antimicrobial agents in the formulary (IB)

Implement a system to prompt clinicians to use the appropriate agent and regimen for a given clinical situation (IB)

Provide clinicians with antimicrobial susceptibility reports at least annually (IB)

Surveillance

Establish a system that the lab promptly notifies IC, Medical Director, or designee if a novel resistance pattern is detected (IB)

Hospitals and LTCF labs: Lab protocols for storing isolates for elected molecular

typing when needed to confirm epi-link (IB) System to detect and communicate evidence of

MDRO’s in clinical isolates (IB) Prepare facility and special care unit specific

antimicrobial susceptibility reports and monitor for resistance changes (IA/IB/IC)

Monitor trends in incidence of target MDRO’s over time (IA)

Environmental Measures

Follow recommended cleaning, disinfection, and sterilization guidelines

Dedicate non-critical medical items Prioritize room cleaning

Focus on cleaning and disinfecting frequently touched surfaces and equipment in immediate vicinity of patient.

Decolonization

Generally not routinely recommended Do not use topical Mupirocin to routinely

decolonized MRSA patients as a component for MRSA control in any healthcare setting (IB)

Limit decolonization to health care providers found to be colonized with MRSA who have an epi-link to ongoing transmission of MRSA to patients (IB)

Consult with experts on a case-by-case basis regarding decolonization.

Tier 1 - IC Precautions to Prevent TransmissionAcute Care Settings

Follow Standard Precautions in all healthcare settings (IB)

Contact precautions in acute care settings Implement for all patients known to be colonized or

infected with target MDRO (IB) Patient placement in single room or cohort (IB)

Tier 2 - Intensified MDRO ControlAcute Care Settings

Contact precautions should be used routinely for all infected and known colonized patients (IA) Don gowns and gloves upon entry to patient’s room or

cubicle (IB) Maintain contact precautions if active surveillance

cultures are obtained until results are negative (IB) Patient placement-single room or cohort Implement admission and placement policies as

needed (IB) Stop new admissions to the unit or facility if transmission

continues despite intensified control measures (IB)

Infection Control and preventionExtended/Long-term Care

Different patient population Mobile population Cognitive issues may be a factor Incontinence issues may be a factor Frequent hospitalizations Increased antibiotic use Colonization pressure Double-room/roommates Group living for extended time period Group activities This is their home!!

http://www.apic.org/Resource_/TinyMceFileManager/Practice_Guidance/id_APIC-SHEA_GuidelineforICinLTCFs.pdf

IC Precautions to Prevent Transmission LTCFs Tier 1 and Tier 2

Tier 1: Follow Standard Precautions in all healthcare settings (IB) Consider the individual patient’s clinical situation and facility

resources in deciding whether to implement Contact Precautions (II)

Patient placement in single room or cohort (IB)

Tier 2: Use contact precautions routinely for patients colonized or

infected (IA) Modify Contact Precautions for patients whose site of

colonization or infection can be contained and who can observe good hand hygiene to enter common areas and group activities

Maintain Contact Precautions until active surveillance cultures are negative (IB)

Implement policies for patient admission and placement (IB) Stop admissions if transmission continues (IB)

Patient Placement

When single-patient rooms are available, assign priority for these rooms to patients with known or suspected MDRO colonization or infection.

When single-patient rooms are not available, cohort patients with the same MDRO in the same room or patient-care area.

When cohorting patients with the same MDRO is not possible, place MDRO patients in rooms with patients who are at low risk for acquisition of MDROs and associated adverse outcomes from infection and are likely to have short lengths of stay.

Give highest priority to those patients who have conditions that may facilitate transmission, e.g., uncontained secretions or excretions.

Impact of Contact precautions on patient well-being

Studies found that HCP, including attending physicians, were half as likely to enter the rooms of or examine patient on contact precautions

Patients placed on Contract Precautions for MRSA had significantly more preventable adverse events, expressed greater dissatisfaction with their treatment and had less documented care than non-isolated patients

Infection PreventionCommonality

Proper hand hygiene, proper use of PPE, Proper environmental cleaning, and proper cleaning, disinfection and/or sterilization of equipment, and avoiding reuse of single-use items.

Infection Prevention encompasses many factors Breaks or missteps with any of these factors can

result in risk of infection Patients Staff Visitors

Patient

Staff

Visitors

Radiation

Diabetes

Surgical incision

Invasive devices/

Lines

Immune Status

Medication

Environmental

Cleaning

Equipment

Disinfection

Sterilization

Personal

Protective

Equipment

Patient & Staff

Education

Hand

Hygiene

Contaminated Hands

Reusable Equipment

Environmental Surfaces

Sick Visitors

Ill Employees

Medical Procedures

Improper DisinfectionAnd Sterilization

Multidose vials

Reuse of single-use items

Improper PPE Use

Contaminated meds

Prolonged Use of lines

HAND HYGIENE

Hand Hygiene

Hand hygiene should be a cornerstone of prevention efforts Prevents transmission of pathogens via hands of healthcare

personnel As part of a hand hygiene intervention, consider:

Ensuring easy access to soap and water/alcohol-based hand sanitizer

Education for healthcare personnel and patients Observation of practices - particularly around high-risk

procedures (before and after contact with colonized or infected patients)

Feedback – “Just in time” feedback if failure to perform hand hygiene observed Positive and Negative feedback

http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

Alcohol Hand SanitizerKnow the Regulations

Fire Code and/or Life Safety The maximum individual dispenser fluid

1.2 Liters (1200mL; 0.3 gallons) for dispensers in patient rooms, corridors and areas open to corridors

Corridors must be at least 6 feet wide 2.0 Liters (2000mL; 0.5 gallons) for dispensers in suites of

rooms. Dispensers must be installed at least 4 feet apart Dispenser must measure at least 6 inches from the

center line to the ignition source. Dispensers installed directly over carpeted floors shall be

permitted only in sprinkler smoke compartments More storage and use regulations can be found at:

https://www.ndhealth.gov/LifeSafety/PDF_Files/ALCOHOL_BASED_HAND_RUB_SOLUTIONS.pdf

Poor Adherence to Hand HygieneSelf Reported

• Hand washing agents cause irritation and dryness • Sinks are inconveniently located/shortage of sinks • Lack of soap and paper towels • Often too busy/insufficient time • Understaffing/overcrowding • Patient needs take priority • Hand hygiene interferes with health-care worker relationships with patients • Low risk of acquiring infection from patients • Wearing of gloves/beliefs that glove use obviates the need for hand

hygiene • Lack of knowledge of guidelines/protocols • Not thinking about it/forgetfulness • No role model from colleagues or superiors • Skepticism regarding the value of hand hygiene • Disagreement with the recommendations • Lack of scientific information of definitive impact of improved hand hygiene

on health-care–associated infection rates

Increasing WorkloadH

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Com

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Personnel with heavy workloads have little time to wash their hands

A recent study showed that the busier healthcare workers are, the less likely they are to wash their hands when recommended.

• Sinks used for hand washing are often installed in inconvenient locations.

• Can you find the sink in this picture?

Sinks are often poorly located

• The sink is located behind the patient’s bed and behind several IV pumps.

(see arrow)

• Personnel are unlikely to use hand washing sinks if they are not readily accessible.

• Be involved with all remodel and construction projects from the design phase to completion of the project

Location, location, location ...

• Frequent hand washing with soap and water often causes skin irritation and dryness.

• Staff should be involved with hand hygiene product selection

• Facilities should provide lotion that is compatible with soaps, sanitizers, and gloves

Another reason why personnel don’t wash their hands often

Many personnel don’t realize when they have germs on their hands

Healthcare workers can get 100s or 1000s of bacteria on their hands by doing simple tasks, like: •pulling patients up in bed •taking a blood pressure or pulse •touching a patient’s hand •rolling patients over in bed •touching the patient’s gown or bed sheets •touching equipment like bedside rails, over-bed tables, IV pumps

Culture plate showing growth of bacteria 24 hours after a nurse placed her hand on the plate

Using alcohol-based hand sanitizer to improve hand hygiene

More than 20 published studies have shown that alcohol-based hand sanitizers are more effective than either plain soap or antibacterial soaps in reducing the number of live bacteria on the hands.

Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

When compared to traditional soap and water hand washing, alcohol hand sanitizers have the following advantages:

• take less time to use • can be made more accessible than sinks • cause less skin irritation and dryness • are more effective in reducing the number of

bacteria on hands • makes alcohol-based hand sanitizers readily

available to personnel • has led to improved hand hygiene practices

Infection Preventionists need to assess that hand sanitizer is available in convenient locations

Alcohol-based Hand Sanitizer Advantages

Soap and Water has it’s Place

• For hands that are visibly dirty or contaminated withproteinaceous material or are visibly soiled with blood or other body fluids• Before eating• After using the restroom• After exposure to C. difficile or Bacillus anthracis is suspected

or proven.

Hand sanitizer dispensers should be placed in safe locations• Pediatric units, chemical dependency units, cognitive and

behavioral settings

Hand Sanitizer has it’s Place also

Measuring Hand Hygiene Methods of Measure

Consider two methods of measurement: Observation

Time consuming/bias Patient or visitor/family surveys

Patient knowledge/cognition/recall Product Measurement

Proxy measure/inaccuracies Electronic Monitoring

Cost

Measuring Hand Hygiene Compliance

Objective Measurable Unbiased Consistent Repeatable Accurate Comparable

Observation most common type used

Issues include: Hawthorne Effect Time Consuming Bias by observers Inability of

anonymously observe behind closed doors

Staff education and feedback are very important components to a hand hygiene program

0 10 20 30 40 50 60

Room Door Handle

IV Pump Button

Bath Door Handle

Side Rails

BP Cuff

Overbed Table

Patient Gown

Bed Linen

Percent of Surfaces Contaminated

Frequency of Environmental Contaminationof Surfaces in the Rooms of Patients withMethicillin-Resistant S. aureus (MRSA)Resistant bacteria on

the skin or in the gastrointestinal tract of patients can often be found on common items

Healthcare workers can contaminate their hands by touching environmental surfaces near affected patients.

How Healthcare workers contaminate their hands

ENVIRONMENTAL CLEANING

VRE on Hands and Environmental Surfaces

Studies have been conducted to monitor thetransmission of VRE• Up to 41% of healthcare worker’s hands sampled

(after patient care and before hand hygiene) were positive for VRE1

• VRE were recovered from a number of environmental surfaces in patient rooms

• VRE survived on a countertop for up to 7 days2

1 Hayden MK, Clin Infect Diseases 2000;31:1058-1065.2 Noskin G, Infect Control and Hosp Epidemi 1995;16:577-581.

The Inanimate Environment Can Facilitate Transmission

~ Contaminated surfaces increase cross-transmission ~

X represents VRE culture positive sites

Disinfectant Use

In patient-care areas, visibly soiled areas should first be cleaned and then chemically disinfected.

For disinfection, the precleaned areas should be moistened with the appropriate disinfectant for the stated contact time and allowed to air dry.

Gloves should be worn during cleaning and decontaminating procedures.

Types of DisinfectantsSpaulding Categorization

There are three levels of disinfection: High Level

kills all organisms, except high levels of bacterial spores

Intermediate Level kills mycobacteria, most viruses, and bacteria as

chemical germicide registered as a "tuberculocide" by the EPA

Low Level kills some viruses and bacteria as a chemical germicide

registered as a hospital disinfectant by the EPA.

http://www.cdc.gov/hicpac/Disinfection_Sterilization/2_approach.html

Low or Intermediate Level Disinfection

Contact Time Short contact time may be difficult to obtain Room turn around time can be a factor Orientation and ongoing staff education

Quiz staff and provide real-time education

Manufacturer recommendations Review to make sure disinfectants can be used

CDC guidelines Some non critical equipment may not have M.

recommendations available. CDC guidelines should be considered based on equipment construction and usage.

Types of DevicesSpaulding Categorization

Critical Devices Reusable instruments or devices that enter sterile tissue,

including the vascular system of any patient, and devices through which blood flows should be sterilized before reuse.

Semi Critical Devices Reusable devices or items that touch mucous membranes

should, at a minimum, receive high-level disinfection between patients.

Noncritical Devices Except on rare and special instances, items that do not

ordinarily touch the patient or touch only intact skin are not involved in disease transmission, and generally do not necessitate disinfection between uses on different patients.

Environmental Cleaning for C. difficile

Bleach can kill spores, whereas other standard disinfectants cannot

Limited data suggest cleaning with bleach reduces C. difficile transmission 1:10 dilution prepared fresh daily 1:10 Prepackaged with stabilizers

Two before-after intervention studies demonstrated benefit of bleach cleaning in units with high endemic CDI rates

Therefore, bleach may be most effective in reducing burden where CDI is highly endemic

Mayfield et al. Clin Infect Dis 2000;31:995-1000.Wilcox et al. J Hosp Infect 2003;54:109-14.

Environmental Cleaning Strategies

Assess adequacy of cleaning before changing to new cleaning products

Ensure that environmental cleaning is adequate and high-touch surfaces are not being overlooked

One study used a fluorescent environmental marker to assess cleaning: only 47% of high-touch surfaces in 3 hospitals were cleaned sustained improvement in cleaning of all objects, especially in

previously poorly cleaned objects, following educational interventions with the environmental services staff

Carling et al. Clin Infect Dis 2006;42:385-8.

CDC RecommendationsEnvironmental Cleaning Evaluations

Level One (basic program) Level Two (advanced program

http://www.cdc.gov/HAI/pdfs/toolkits/Environ-Cleaning-Eval-Toolkit12-2-2010.pdf

http://www.cdc.gov/HAI/toolkits/Environmental-Cleaning-Checklist-10-6-2010.pdf

Observation Feedback

Covert environmental marking Real time feedback for Environmental Services

staff Let them see the areas that were missed

Test at least 3 times a year using different time frames to capture different cleaning variances

Provide overall rates and findings to Environmental Services, Infection Control Committee and Administration

CLEANING OF PATIENT CARE EQUIPMENThttp://www.cdc.gov/HAI/prevent/sd_medicalEquip.html

Manufacturer’s Recommendations

Is IP staff involved and providing input into new equipment and devices BEFORE they’re ordered? Can new equipment be cleaned properly with the

disinfectants available? Are manufacturer recommendations accessible

to the people responsible for cleaning and disinfecting the equipment? Can staff pull the recommendations on demand and

are they following them correctly?

Processing of Medical Devices

Medical devices that require sterilization or disinfection must be thoroughly cleaned to reduce material/bio burden before being exposed to the germicide.

Germicide and/or device manufacturers' instructions should be closely followed.

Disinfection of Medical Devices

Disinfection means the use of a chemical procedure that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial endospores) on inanimate objects.

Types of Disinfectants

There are three levels of disinfection: High Level

kills all organisms, except high levels of bacterial spores, and is effected with a chemical germicide cleared for marketing as a sterilant by the FDA

Intermediate Level kills mycobacteria, most viruses, and bacteria with a

chemical germicide registered as a "tuberculocide" by the EPA

Low Level kills some viruses and bacteria with a chemical germicide

registered as a hospital disinfectant by the EPA.

Types of Devices Noncritical Devices

Except on rare and special instances, items that do not ordinarily touch the patient or touch only intact skin are not involved in disease transmission, and generally do not necessitate disinfection between uses on different patients.

These items include crutches, bed boards, blood pressure cuffs, and a variety of other medical accessories.

Consequently, depending on the particular piece of equipment or item, washing with a detergent or using a low-level disinfectant may be sufficient when decontamination is needed.

If noncritical items are grossly soiled with blood or other body fluids, follow instructions outlined in the section on HIV-related sterilization and disinfection of this information system.

http://www.cdc.gov/HAI/prevent/sd_medicalDevices.html

Exceptions to Standard Disinfection

Exceptional circumstances that require noncritical items to be either dedicated to one patient or patient cohort, or subjected to low-level disinfection between patient uses are those involving: Patients infected or colonized with drug-resistant

microorganisms judged by the infection control program, based on current state, regional, or national recommendations, to be of special or clinical or epidemiologic significance MRSA, VRE, CRE, C. difficile

Patients infected with highly virulent microorganisms, e.g., viruses causing hemorrhagic fever (such as Ebola or Lassa).

Prions

Types of Devices

Semi Critical Devices Reusable devices or items that touch mucous

membranes should, at a minimum, receive high-level disinfection between patients.

These devices include reusable flexible endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy equipment, dental instruments that do NOT penetrate soft tissue and bone.

The other ones: Vaginal probes and speculums, anoscopes, rectal

thermometers Are yours single-use disposable or reprocessed?

Types of Devices

Critical Devices Reusable instruments or devices that enter sterile

tissue, including the vascular system of any patient, and devices through which blood flows should be sterilized before reuse.

Dental equipment that penetrates soft tissue and bone.

http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf

Sterilization of Medical Devices

Sterilization means the use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores.

The major sterilizing agents used in hospitals are: moist heat by steam autoclaving, chemical, ethylene oxide gas, and dry heat.

http://www.cdc.gov/HAI/prevent/sd_medicalDevices.html

Single-Use vs. Multi-Use Items

Single-use is just that-it is used one time for one patient and disposed of properly.

Multi-use items can be used more than once but manufacturer’s recommendations must be followed regarding amount of use, cleaning and disinfection between use, labeling, and storage.

Reuse of single-use devices -FDA jurisdiction with strong mandates to insure the device is safe for use Hospital or third-party processor is considered the manufacturer

and held to the same standards and liability Provide education to staff so they understand what is meant

by single-use vs. reusable equipment, supplies, or devices Have a policy defining your facility’s processes

http://www.oneandonlycampaign.org/content/cdc-guidelines

http://www.cdc.gov/hicpac/Disinfection_Sterilization/14_00ReuseMedicalDevices.html

PERSONAL PROTECTIVE

EQUIPMENT (PPE)

Personal Protective Equipment (PPE)

“Specialized clothing or equipment worn by an employee for protection against infectious materials” (OSHA)

Improve personnel safety in the healthcare environment through appropriate use of PPE.

Regulations and Recommendations for PPE

OSHA issues workplace health and safety regulations. Regarding PPE, employers must: Provide appropriate PPE for employees Ensure that PPE is disposed or reusable PPE is cleaned,

laundered, repaired and proper storage OSHA also specifies circumstances for which PPE is

indicated CDC recommends when, what and how to use PPE

https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS

http://www.cdc.gov/hicpac/pdf/isolation/isolation2007.pdf

Factors Influencing PPE Selection

• Type of exposure anticipated– Splash/spray versus touch– Category of isolation precautions

• Durability and appropriateness for the task

• Fit

PPE for Standard Precautions

• Gloves – Use when touching blood, body fluids, secretions, excretions, contaminated items; for touching mucus membranes and nonintact skin

• Gowns – Use during procedures and patient care activities when contact of clothing/ exposed skin with blood/body fluids, secretions, or excretions is anticipated

PPE for Standard Precautions

• Mask and goggles or a face shield – Use during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions

PPE for Enhanced Precautions

• Expanded Precautions include– Contact Precautions– Droplet Precautions– Airborne Infection Isolation

Use of PPE for Enhanced Precautions

• Contact Precautions – Gown and gloves for contact with patient or environment of care (e.g., medical equipment, environmental surfaces)

• these will likely be required upon entering the patient’s environment

• Droplet Precautions – Surgical masks within 3-6 feet of patient

• Airborne Infection Isolation – Particulate respirator* *Negative pressure isolation room also required

Respiratory Protection• Purpose – protect from inhalation of

infectious aerosols (e.g., Mycobacterium tuberculosis -TB)

• PPE types for respiratory protection– Particulate respirators– Half or full-face elastomeric respirators– Powered air purifying respirators (PAPR)

• What is your facilities TB plan?– Accept the patient– Transfer the patient

Elements of a Respiratory Protection Program

• Medical evaluation• Annual Fit testing• Training• Fit checking before use

http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf

For additional information on respirators….

• http://www.cdc.gov/niosh/npptl/respirators/ respsars.html

• http://www.cdc.gov/niosh/99-143.html

• http://www.cdc.gov/niosh/topics/respirators

Sequence* for Donning PPE

• Gown first• Mask or respirator• Goggles or face shield• Gloves

*The combination of PPE will affect sequence – be practical

Staff education:

“Contaminated” and “Clean” Areas of PPE

• Contaminated – outside front• Areas of PPE that have or are likely to have

been in contact with body sites, materials, or environmental surfaces where the infectious organism may reside

• Clean – inside, outside back, ties on head and back

• Areas of PPE that are not likely to have been in contact with the infectious organism

Hand Hygiene• Perform hand hygiene immediately after

removing PPE– If hands become visibly contaminated during PPE

removal, wash hands before continuing to remove PPE

• Wash hands with soap and water or use an alcohol-based hand rub

* Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand sanitizer

Key Points About PPE

• Don before contact with the patient, generally before entering the room

• Use carefully – don’t spread contamination

• Remove and discard carefully, either at the doorway or immediately outside patient room; remove mask/respirator outside room

• Immediately perform hand hygiene

PPE Use in Healthcare Settings:Final Thoughts

PPE is available to protect staff from exposure to infectious agents in the healthcare workplace

Periodically assess staff compliance to PPE usage and communicate the findings to staff

Patient

Staff

Visitors

Radiation

Diabetes

Surgical incision

Invasive devices/

Lines

Immune Status

Medication

Environmental

Cleaning

Equipment

Disinfection

Sterilization

Personal

Protective

Equipment

Patient & Staff

Education

Hand

Hygiene

Contaminated Hands

Reusable Equipment

Environmental Surfaces

Sick Visitors

Ill Employees

Medical Procedures

Improper DisinfectionAnd Sterilization

Multidose vials

Reuse of single-use items

Improper PPE Use

Contaminated meds

Prolonged Use of lines

Putting it all Together

An Infection Preventionist is an investigator and an advocate for patients and staff Ask questions Be observant Find solutions Work as a team-you are the leader of many Stay current on national guidelines Network-Where do you go for answers?

References/Resources

Speak to the relationship between Infection Prevention methods and reduced transmission of multidrug resistant organisms and C. difficile.http://www.cdc.gov/hicpac/pdf/MDRO/MDROGuideline2006.pdfhttp://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

Explain the importance of hand hygiene including barriers preventing proper hand hygienehttp://www.cdc.gov/handhygiene/guidelines.htmlhttp://www.cdc.gov/handhygiene/download/hand_hygiene_core.pdf Describe environmental cleaning issues and assessment methods for cleaning validationhttp://www.cdc.gov/hai/toolkits/evaluating-environmental-cleaning.htmlhttp://www.cdc.gov/HAI/toolkits/Environmental-Cleaning-Checklist10-28-2010.doc Discuss recommendations for equipment cleaning and disinfectionhttp://www.cdc.gov/hicpac/pdf/guidelines/disinfection_nov_2008.pdf List the personal protective equipment used to prevent the spread of organismshttp://www.cdc.gov/HAI/settings/outpatient/outpatient-care-gl-standared-precautions.htmlhttps://www.osha.gov/SLTC/etools/hospital/hazards/univprec/univ.html  

THANK YOUJulie Jacobson, RN BSN CIC

Dacotah Plains APIC Chapter

julie.jacobson@sanfordhealth.org

http://www.apic.org/